Basic Information
| Provider Information | |||||||||
| NPI: | 1710965223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VONGILLERN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 11/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 036062158 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | 29517 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207X00000X | 036062158 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 29517 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1602943 | 01 | FIRST HEALTH | OTHER | P00756425 | 01 | IA | RAILROAD MEDICARE | OTHER | 020376 | 01 | HEALTH ALLIANCE | OTHER | 0910729 | 05 | IA | MEDICAID | 8121085 | 01 | IL | BCBS | OTHER | 05283 | 01 | WELLMARK | OTHER | 17658 | 01 | MIDLANDS CHOICE | OTHER | 036062158 | 05 | IL | MEDICAID | 20177 | 01 | IA HEALTH SOLUTIONS | OTHER | 91390 | 01 | WELLMARK | OTHER | 99205 | 01 | WELLMARK | OTHER | 200011702 | 01 | RR MEDICARE | OTHER | IA0189 | 01 | IA | JOHN DEERE FAMILY | OTHER | S50606 | 01 | IL | JOHN DEERE FAMILY | OTHER |